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Marc H. Sencer, MDJune 22, 2015

Practice integration means practice expansion.

If you are completely satisfied with the reimbursements and friendliness of the payers you work with, then stay on your current course. But if you are worried about decreasing reimbursements and the increasingly complex hoops you have to jump through (e.g., transitioning to ICD-10 codes) just to get paid for work you have already done, you may be considering making some changes.

Medical integration is potentially the single most effective weapon you have in your arsenal against decreasing reimbursements and abuse by third-party payers. For the purposes of this article, medical integration can include physical therapy with or without the addition of a medical doctor (e.g., a DC-PT practice), as well as the addition of physician extenders such as nurse practitioners.

New vistas

As a chiropractor, in most states you are limited in terms of the services you can provide and bill third-party payers for. Medicare hardly allows you to bill for anything, and for that reason many chiropractors do not see Medicare patients.

When you integrate, there is effectively no limit to what can add to your practice. In fact, your practice becomes whatever co-professionals you hire.

Hire a neurologist and you become a neurology practice. Hire a physical therapist and suddenly the world of Medicare opens up as you’ve become a physical therapy practice.

There is also safety in numbers. The more services you offer, the more you can endure reimbursement changes to one or two of them. For example:

Consider nerve conduction studies. Traditionally, these have been huge profit centers and, for many neurology practices, they were the bread-and- butter service offered.

Then, fairly recently, the Centers for Medicare and Medicaid Services (CMS) changed the codes and reimbursement structure for these tests. For those practices that depended almost entirely on them for income, this was a disaster. But those practices that offered a range of other services such as sleep lab, stroke rehab, and other neurodiagnostic tests withstood the change thanks to the many other procedures they could still perform at full billing rates.

So in addition to adding more income in the short term, integration can be a powerful hedge in the long run against adverse changes in the reimbursement picture.

Hedge funds

Some chiropractors who are doing quite well in the personal injury (PI) arena are satisfied with their practices. Many of these doctors question the value of adding private-pay and Medicare patients to their practices. Why would they want the extra headaches and overhead?

The answer is that by increasing the number of profit centers and payers you have, you create a powerful hedge against the day when PI reform comes to your state. Unfortunately, this is a trend being seen across the country.

For a concrete example of how a PI practice can be decimated, look no further than New Jersey after major PI reforms were implemented.

Many avenues lead to integration, including simply adding a PT, putting in a full fluoroscopy suite, or hiring an anesthesiologist to do interventional pain procedures in the office. While most chiropractors opt for expanding musculoskeletal medicine, some doctors go in a completely new direction by adding primary care, for example, to their practice.

King cash

Whichever direction you go, one thing is essential: Your plan should include some cash-based services. The trend in insurance reimbursement is downward and medical doctors are being squeezed, albeit not as much as chiropractors.

Many cash-based services can be beneficial such as platelet-rich plasma injections, anti-aging medicine, functional medicine, and medical spa services, to name a few. Even though these may be new to you and lie beyond your comfort zone, you can hire trained professionals to do this work and training is available for doctors and other providers.

Trends in insurance reimbursement are not going to get better anytime soon, and probably will continue to worsen. No one will feel the effects of this more than the solo chiropractor, who may only be able to bill for adjustments and related modalities. Yet whether you are a small solo practice or a large one with multiple doctors, you can make more money and weather reimbursement changes in the future if you are integrated.

It can take several months and up to a year before you are operating with the services you may want to add, and some practices never stop adding new things. The sooner you start moving toward an integrated practice, the sooner you can enjoy the benefits.

Marc H. Sencer, MD, is the president of MDs for DCs, which provides intensive one-on-one training, medical staffing, and ongoing practice management support to chiropractic integrated practices. He can be reached at 800-916-1462 or through mdsfordcs.com.